Current Orthopaedic Practice

An innovative method of hamstring graft preparation and a new concept of intra-tunnel tendon fixation: Biomechanical evaluation
--Manuscript Draft-Manuscript Number: Full Title: Article Type: Keywords: Manuscript Region of Origin: Abstract: COP-S-12-00015 An innovative method of hamstring graft preparation and a new concept of intra-tunnel tendon fixation: Biomechanical evaluation Original Research anterior cruciate ligament (ACL); ACL reconstruction; Hamstrings; cyclic loading; preconditioning. BELGIUM Background: Current anterior cruciate ligament reconstruction using hamstrings (HS) grafts still entails difficulties for adequate graft fixation. A new technique for hamstring ACL graft fixation called (TLS) Tape locking screw has recently been described [1,2]. We propose to evaluate the mechanical properties of this new fixation method by performing a controlled laboratory study. Methods: In a laboratory environment we performed a series of three tests on 10 human semi tendinosus grafts assessing their load to failure before and after application of different cyclical loads. We also tested the new fixation device in isolation for its load to failure before and after cyclical loading as well as the complex graftfixation (CGF) for both load to failure before and after application of cyclical loads. Results: After 1500 cycles loading, the mean ultimate failure load (UFL) and stiffness were respectively 1916N and 605N/mm for the graft in isolation, 1535N and 452N/mm for the fixation device, 1568N and 232N/mm for the CGF which remained similar after 33600 cycles (1553N and 223N/mm). After 1500 cycles loading, the mean fixation's lengthening was negligible (0.6mm).The CGF lengthening was respectively 6mm and 7,6mm after 1500 and 33600 cycles but only 1.2mm and 2.6 mm after preconditioning. Conclusions: The Taper Lock Screw (TLS) system provides in vitro outstanding mechanical characteristics. Preconditioning process is mandatory.

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*Structured Abstract and Keywords

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An innovative method of hamstring graft preparation and a new concept of intra-tunnel tendon fixation: Biomechanical evaluation

Background: Current anterior cruciate ligament reconstruction using hamstrings (HS) grafts still entails difficulties for adequate graft fixation. A new technique for hamstring ACL graft fixation called (TLS) Tape locking screw has recently been described [1,2]. We propose to evaluate the mechanical properties of this new fixation method by performing a controlled laboratory study. Methods: In a laboratory environment we performed a series of three tests on 10 human semi tendinosus grafts assessing their load to failure before and after application of different cyclical loads. We also tested the new fixation device in isolation for its load to failure before and after cyclical loading as well as the complex graft-fixation (CGF) for both load to failure before and after application of cyclical loads. Results: After 1500 cycles loading, the mean ultimate failure load (UFL) and stiffness were respectively 1916N and 605N/mm for the graft in isolation, 1535N and 452N/mm for the fixation device, 1568N and 232N/mm for the CGF which remained similar after 33600 cycles (1553N and 223N/mm). After 1500 cycles loading, the mean fixations lengthening was negligible (0.6mm).The CGF lengthening was respectively 6mm and 7,6mm after 1500 and 33600 cycles but only 1.2mm and 2.6 mm after preconditioning.

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Conclusions: The Taper Lock Screw (TLS) system provides in vitro outstanding mechanical characteristics. Preconditioning process is mandatory.

Keywords: TLS; anterior cruciate ligament (ACL); ACL reconstruction; Hamstrings; cyclic loading; preconditioning.

*Manuscript (No Author Information)

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Introduction:

Early rehabilitation programs after ACL reconstruction have been validated after bonepatellar tendon-bone grafts [3] but their use remain controversial after HS graft reconstructions[4,5] mainly because of residual fixation problems at the tibial site. A new hamstring graft reconstruction technique [1,2] called Tape locking screw technique (TLS) has been designed to address these problems . The purpose of this study is to evaluate the mechanical value of the TLS fixation

Material and Methods The Graft (fig1-A1-5) Semi-tendinosous specimens collected from human cadavers (age: 47-81.Mean: 68,811,43) were deep frozen and stored. The day of testing, the tendons were thawed by immersion into room temperature saline solution. Each graft's ends were attached together using a few single stitches plus one continuous suture using No 1 non-absorbable sutures (ETHICON MERSUTURE) . By twisting the graft, a figure of 8 loop was obtained , then folded on itself to make a closed 4 tendon strands loop. After measurement of its length and diameter, each specimen was mounted to a tensile testing machine (M.T.S.-10.000Ncapacity). The tension was applied through two metal rods passing freely through each grafts end. The Fixation (fig1-B1-3) It is obtained by fixing suspension tapes to the bone with a special interference screw called TLS (Tape Locking Screw), The TLS screw (10mm) has a conical shape, deep rounded threads and a large blunt tip to avoid any potential abrasive effect to the tapes.

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Specimen's preparation Human femoral heads were collected, deep frozen and stored until the day of mechanical tests. Each specimen thickness was measured and bone density recorded using a HOLOGIC QDR 4000 machine-DEXA. The results were normalized (specimen bone density divided by its own thickness times the average thickness of all specimens). A 4 mm hole was drilled through the femoral head and a 10 mm socket was reamed through one extremity. The other tunnel extremity was tapped to prepare the screw bed (fig2-A) After passing through the bone channel, a 7mm MERSILENE tape was hanged on the transversal rod of a 10 mm tube which was then introduced into the bone socket by tensioning the tapes. A TLS screw was introduced between both tape ends. The so prepared specimen was locked in a metal box fixed to the bottom of the machine. The tube was passed through a small hole in the box top and fixed to the tensile machine. (fig2-B) The Complex Graft-Fixation (CGF) The same traction set up was used as for the fixation specimens but replacing the traction tube by the semi-tendinosus graft (fig2-C). Biomechanical testing All mechanical tests were performed at the CRITT-Charleville France in June 2002. To standardize specimens initial conditions, the following protocol was first applied. 20N/30sec - then 10cycles: 50-250N- then 20N/30sec. Load to failure test (test 1) All specimens were loaded at the rate of 1mm/sec. Number of tests: 5 grafts and 5 fixation alone specimens.

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The ultimate failure load (UFL) was recorded and the stiffness measured in the linear part of the stress-displacement curve. Cyclic loading tests (test2) After standardizing initial conditions and a rest period of 2 minutes, the specimen's length (initial length) was measured; 1500 cycles loading from 20 to 500 newtons were then applied at a rate of 2 cycles/sec. After the test, another 20N rest period was allowed to the specimen and its length (final length) was again recorded. The difference between the initial and final specimens length determined the total rate of elongation without preconditioning. In four of five CGF specimens, the initial length was recorded as described. Then, a 500N static load was applied for 3 minutes and the modified value of the initial length was recorded. This modified initial length compared to the final length after cyclic loading determined the total rate of elongation with preconditioning. A final test 1 was then applied. Number of tests: 5 grafts, 5 fixation, 5 CGF (one fixation was loaded up to 6600 cycles)

Long duration cyclic loading tests (test3) 3 CGF specimens were subjected to very long cyclic loading tests alternating 600 cycles of 25-250N with 600 cycles of 50-500N for 24 hours which produced 33600 cycles before the final test 1. Statistical Analysis Conventional statistical methods were used to analyse the observed results. The Analysis of Variance (ANOVA) was used to test for any difference between the means of the relevant groups of experimentation. This approach is a more conservative approach than proceeding in multiple paired T-tests comparisons when more than two groups are being compared.

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Regression techniques were applied when appropriate. The data were analysed using the Statistix 3.5 analytical software. Results (fig3-4) Tests to the graft only There was no tendon failure during the cyclic loading tests except one single histologically defective tendon which failed early under 500N load and was replaced by a healthy one. Before cyclic loading, the mean UFL was 1302140N (Range1150-1500N) After cyclic loading, there was no sign of deterioration of the tendon strength which was even reinforced up to 1916349N (Range:1480-2290N), the difference being statistically significant (p=0.0065). The same finding was made for the stiffness which showed a statistically significant increase from 26223N/mm before cyclic loading, to 60540N/mm after cyclic loading (p0.001) The tendon loop elongation after 1500cycles of traction (difference between the final length after cyclic loading and initial length) was 3.50.4mm.

Tests to the fixation only There was no fixation failure during the cyclic loading tests. The mean UFL remained statistically similar before cyclic loading (1742397NRange:1250-2240N) and after cycles (1535370N- Range:1140-1920) (p=0.5602/NS). The mean fixation stiffness also remained similar before cyclic loading (38456 N/mm) and after cyclic loading (452113.2 N/mm), (p=0.5134/NS). The fixation's residual elongation after the cyclical test was very low (0.60.2mm). Some crushing of the femoral head's cartilage against the top of the traction metal box could explain most of this small lengthening.

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Tests to the complex graft-fixation(CGF) In this group, all specimens were submitted to cyclic loading before the final test to failure. There was no specimen failure during the 1500 cycles or even the 33600 cycles tests. The mean UFL of the CGF group (1568247N- Range1310-1930N) was quite similar to that of the fixation group (1535397N).(p=0.8766/NS). The three specimens tested for 24 hours (33600 cycles) showed no sign of progressive failure. The UFL of these specimens (1553362N) was indeed quite similar to the mean UFL of the 1500 cycles group (1568247N) (p=0.9471/NS) and their stiffness (22322 N/mm) remained also the same as the 1500 cycles group (23224N/mm). (p=0.6280/NS) Without preconditioning, the elongation rate was 61.5mm after 1500 cycles loading (20500N) .It dropped significantly to 1.20.2mm minutes prior to the test.(p=0.0036) The same statistically significant difference was observed for the 33600 cycles specimens, their final elongation rate dropping from 7.60.8mm without preconditioning to 2.60.2 mm. with preconditioning.(p=0.0047) after a 500N static load applied for 3

Bone mineral density All bone density measurements are shown in table 2. A quite significant correlation (P=0.0636,Radj.=0.15) was observed between the bone density (normalized measurements) and the pull-out force(fig5) .

Discussion Typical ACL hamstring grafts use both the semitendinosus and gracilis tendons to make a 4 strands tendon graft. At the femoral site, the folded part of the graft is appropriate to suspensory or transfixing types of fixations [6,7]. To evenly tension and fix the four free

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tendon ends at the tibial site remains however much more problematic. There is no point to build highly resistant fixations at one site if the other site remains weak. A closed tendon loop is for us, one of the major advantages of the TLS system. One single tendon is to be harvested which minimises the tissue sacrifice. As the graft can be suspended at each end, the same fixation system can be used both at the femoral and tibial site. An equal force distribution through the four strands is automatically obtained when the graft is loaded. Despite a significant tendon saving, this type of graft provides outstanding mechanical properties , compared to many other systems. However, the validity of a short graft comes into question, first of all because of the reduced amount of tendon inserted into the bone and secondly because the suspension linkages are likely to enhance the whole graft construct elasticity and jeopardize its

mechanical properties. The shortened graft design has been validated in three experimental studies. In 2002, Weiler[8] showed that the tendon attaches to bone tissue partly in the tunnel itself and partly where it enters the joint. Intratunnel healing only has a transient effect and fixation at the tunnel entry takes over during the third or fourth postoperative month. In 2008, Zantop[9] showed in goats that using either 15 or 25mm of tendon insertion in the femur does not result in any significant differences in knee kinematics or graft mechanical properties (pull-out strength, stiffness) at six and twelve weeks postoperative. Yamazaki[10] has shown in dogs that at six weeks postoperative, tendon grafts placed in 15 or 5mm bone recesses deep had the same pull-out strength. It has been shown that using linkage material to fix a graft in a non anatomic position could affect the graft stiffness, enhance micromovements and possibly bone tunnels enlargement [11,12,13] Although using linkage material , the TLS screw fixes the tapes close to the graft,

neutralizing its elasticity. Polyester tape material is for us much more appropriate for

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interference screw fixation than the tendon itself. As it lets itself mould closely to the bony reliefs (fig1-B) preventing from potential slippage. From a review article[14] the mean UFL values for HS graft fixations range between 137N (stapled semitendinosus) to 905N (WasherLoc) for the tibial fixations and between 242 (RCI titanium screw) and 699N (EndoButton and three # 5 suture) for the femoral ones. From another study[15,16] the Bone Mulch screw gave the best results (1112295N) among the six femoral fixations and the Intrafix (1332304N) was the best among the six tibial fixation. The stiffness values of the CGF can vary from 8.81N/mm (stapled semitendinosus)[17] to 27356 N/mm (WasherLoc)[18]. A recent study[19] compares the biomechanical properties of three available suspensory fixations systems. (Endobutton CL,RetroButton, ToggleLoc) tested under cyclic loading conditions (50-250N for

1000cycles) in femoral porcine bones .The mean UFL ranged between 798,396,0N (20mm Retrobutton) and 1024,775,0N (20mm EndobuttonCL). The stiffness (after

cycles) ranged between 331,5133,9N (20mm Retrobutton) and 214,720N (20mm Endobutton CL). Although in our protocol the peak level of loading was doubled (500N instead of 250) for 1500 cycles (instead of 1000), the TLS fixation values for UFL (1535370N) and stiffness (452113,2N/mm) were significantly higher. The TLS fixation resistance capacity is also highlighted by our cyclic loading protocol. Many studies used a cyclic load ranging between 50-70N and 200-250N. [11,15,19] Nagarkatti[20] reports hamstring grafts submitted to 5000 cycles loading but the peak load was 150N. Kousa [15,16] tested six HS graft femoral and six tibial fixations submitted to 1500 cycles loading . All but two specimens resisted the 1500 cycles but the maximum peak load was 200N.

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Honl [21] used 60000 cycles and 300N of peak but the force to the graft was applied with an angle of 45 which significantly lowers the resultant pull-out force [22,23]. Giurea [24] used 1100 cycles of 150N and 450N load with rapid failure of all 450N loaded specimens. In our tests, 500N was applied 1500 times along the bone tunnel axis (worst loading scenario) which is, to our knowledge, the highest loading conditions ever reported. The three CGF specimens submitted to 33600 cycles loading successfully achieved the test without any deterioration of their UFL or stiffness. If 1000 cycles roughly correspond to 1 week of standard rehabilitation [20], 33600 cycles loading should mimic a few months of using the graft at an overestimated level. Although this protocol looks disproportionate considering the level of loading commonly required, we think a fixation able to resist extreme mechanical stress, will better work if currently loaded at the half or third of its capacity. The total elongation rate after cyclic loading is another important issue that can affect the final knee stability. The final plastic displacement after cycles reported in Kamelger et al study [19] ranged between 0,660,19mm for the 20mm Endobutton CL and 1,560,44mm for the 20mmToggleLoc, after 1000 cycles of loading from 50-250N. The TLS plastic displacement was 0,60,2 mm which matches the Endobutton CL values but after 1500 cycles instead of 1000 , with a cyclical 500N peak load instead of 250N.We think this very small elongation is not due to a slippage mechanism as the load/time curves (fig6) show that the deformation takes place during the first loading cycles and then tends to plateau. A true slippage mechanism would have produced a steady length increase with time. The TLS CGF elongation rate without preconditioning was of course much higher (60,2mm). About 60% of this lengthening is due to the tendon tissue viscoelasticity[25] as shown by the graft alone elongation rate (3,50,4mm). The rest of the length increase is due

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to small deformations adding up to each other, occurring at each deformable interface (tape-bone;tape-tendon;tendon-traction stirrup). A preconditioning process allowed to neutralize most of this undesirable lengthening. A 500N static load applied to the CGF for 3 minutes made the lengthening drop from 60,2mm(without preconditioning) to 1,20,2mm. For comparison, the residual elongation after 1500 cycles of loading up to 200N (less than half of our loading level) reported by Kousa ranged between 1,50,3mm (Intrafix) and 4,71,5mm (softsilk screw) for the tibial fixations[16] and between

2,20,7mm(Bone Mulch screw) and 4,01,4mm (Bioscrew) for the femoral fixations[15]. Washerlock, for example, showed 3,21,5mm lengthening[16]. The main limitation of our study is that the TLS system was tested alone, without any direct comparison with other fixations. All published similar studies have used wether human knee cadavers [11,21] or animal bones, bovine[26] or porcine [15,19,20]. We used human femoral heads because this material is very easy to collect and handle. Our results have shown (fig5), as expected, that the fixation strength depends on the bone density level.The higher bone density, the higher fixation strength. Comparing our results with others requires then to compare our specimen bone density figures with those of other published datas. This is not very easy to achieve because of a great variety in recording methods. Stadelmayer study[23] however allows some sort of comparison as it used the same bone density recording method as ours (Hologic QDR). The reported values for human proximal epiphysis (mean age: 62,6 years/10490,141g/cm2 to 1,0820,140g/cm2) , are quite similar to ours : 10980,186g/cm2 . This gives an idea of the level of our specimens bone quality. For comparison, the reported bone density of porcine bones is on average 1.42 g/cm2 and 1.30 g/cm2 for young human bones[20]

Conclusion

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The TLS system tested in the above described conditions provided very strong and stiff HS graft fixation. Preconditionning the graft construct is mandatory to neutralise undesirable lengthening occuring within the graft early after its implantation. Based on these biomechanical results, a surgical technique has been developed and used in clinical practice since October 2003 [1,2]. Since it was marketed in and outside of France, more than 18000 cases have been performed with this technique.

Aknowledgments We are grateful to FH orthopedics for their support to achieve this experimental study.

REFERENCES

1. Collette M., Cassard X. The Tape Locking Screw technique (TLS): A new ACL reconstruction method using a short hamstring graft. Orthopaedics & Traumatology: Surgery & Research (2011) 97, 555559

2. Collette M., Cassard X. La technique Tape Locking Screw (TLS) une nouvelle mthode de reconstruction du ligament crois antrieur utilisant une autogreffe courte aux tendons ischiojambiers Revue de chirurgie orthopdique et traumatologique (2011) 97, 540544

3. Shelbourne KD, Gray T: Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation: A two-to nine- year follow-up. Am J Sports Med 25 : 786-795 , 1997

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4. Giurea M Zorilla P, Amis AA, et al: Comparative pull-out and cyclic loading strength tests of anchorage of hamstring tendon grafts in anterior cruciate ligament reconstruction. Am J Sports Med 27:621-625, 1999

5. Howell SM,Taylor MA: Brace free rehabilitation, with early return to activitiy, for knees reconstructed with a double-looped semitendinosus and gracilis graft. J Bone Joint Surg 78A : 814-825 , 1996

6. Clark R, Olsen RE, Larson BJ, et al: Cross-pin femoral fixation: a new technique for hamstring anterior cruciate ligament reconstruction of the knee. Arthroscopy 14 : 258-267 , 1998 7. Chen L, Cooley V, Rosenberg T. ACL reconstruction with hamstring tendon. Orthop Clin North Am. 2003 Jan;34(1):9-18.

8. Weiler A.,Hoffmann R F G, Bail HJ et al :Tendon healing in a bone tunnel. Part II . Histologic analysis after biodegradable interference fit fixation in a model of anterior cruciate ligament reconstruction in sheep Arthroscopy 18:124-135, 2002

9. Zantop T, Ferretti M, Bell KM, Brucker PU, Gilbertson L, Fu FH. Effect of tunnel-graft length on the biomechanics of anterior cruciate ligament-reconstructed knees: intraarticular study in a goat model. Am J Sports Med. 2008 Nov;36(11):2158-66. Epub 2008 Jul 31.

10.Yamazaki S,Yasuda K, Tomita F et al.:The effect of intraosseous graft length on tendon bone healing in anterior cruciate ligament reconstruction using flexor tendon. Knee Surg Sports Traumatol Arthrosc 14:1086-1093 , 2006

284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 17. Kurosaka M, Yoshiya S, Andrish JT : A biomechanical comparison of different surgical techniques of graft fixation anterior cruciate ligament reconstruction Am J Sports Med 15:225-229, 1987 16. Kousa P,J Jrvinen TLN, Vihavainen M et al: The Fixation Strength of Six Hamstring Tendon Graft Fixation Devices in Anterior Cruciate Ligament Reconstruction: Part II: Tibial Site Am. J. Sports Med., 31: 182-188., 2003. 15. Kousa P,J Jrvinen TLN, Vihavainen M et al: The Fixation Strength of Six Hamstring Tendon Graft Fixation Devices in Anterior Cruciate Ligament Reconstruction: Part I: Femoral Site Am. J. Sports Med., 31: 174-181, 2003 14. Brand J Jr., Weiler A, Caborn,DNM et al : Graft Fixation in Cruciate Ligament Reconstruction Am J Sports Med 28:761-774 (2000) 13. Wilson TC,Kantaras A,Atay A et al: Tunnel enlargement after anterior cruciate ligament surgery Am J Sports Med 32:543-549, 2004 12. Hher J, Livesay GA, Ma CB, et al. Hamstring graft motion in the femoral bone tunnel when using titanium button/polyester tape fixation. Knee Surg Sports Traumatol Arthrosc 7:215-219 , 1999 11. Brown CH Jr,Wilson DR,Hecker AT et al.: Graft-bone motion and tensile properties of hamstring and patellar tendon anterior cruciate ligament femoral graft fixation under cyclic loading. Arthroscopy 20 : 922-935 , 2004

310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 23. Stadelmayer DM, Lowe WR, Ilahi OA et al: Cyclic pull-out strength of Hamstring tendon graft fixation with soft tissue interference screws. Influence of screw length. Am J Sports Med 27:778-783, 1999 22. Pena F, Grntveld T, Brown GA et al. Comparison of failure strength between metallic and absorbable interference screws. Influence of insertion torque, tunnel-bone block gap, bone mineral density, and interference Am J Sports Med 24:329-334, 1996 21. Honl M, Carrero V, Hille E, et al.:Bone-patellar tendon-bone grafts for anterior cruciate ligament reconstruction . An in vitro comparison of mechanical behavior under failure tensile loading and cyclic submaximal tensile loading Am J Sports Med 30:549-557, 2002 20. Nagarkatti DG,Mckeon BP,Donahue BS and Fulkerson JP:Mechanical evaluation of a soft tissue interference screw in free tendon anterior cruciate ligament graft fixation. Am J Sports Med 29:67-71, 2001 19.Kamelger FS, Onder U, Schmoelz W, Tecklenburg K, Arora R, Fink C. Suspensory fixation of grafts in anterior cruciate ligament reconstruction: a biomechanical comparison of 3 implants. Arthroscopy. 2009 Jul;25(7):767-76. 18. Magen HE,Howell SM,Hull ML, Structural properties of six tibial fixation methods for anterior cruciate ligament soft tissue grafts Am J Sports Med 27:35-43, 1999

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24. Giurea M Zorilla P, Amis AA, et al: Comparative pull-out and cyclic loading strength tests of anchorage of hamstring tendon grafts in anterior cruciate ligament reconstruction. Am J Sports Med 27:621-625, 1999

25. Graf BK, Vanderby R Jr, Ulm MJ, et al :Effect of preconditioning on the viscoelastic response of primate patellar tendon. Arthroscopy 10 : 90-96 , 1994

26.Weiler A, Hoffmann RF, Sthelin AC, Bail HJ, Siepe CJ, Sdkamp NP.Hamstring tendon fixation using interference screws: a biomechanical study in calf tibial bone.Arthroscopy. 1998 Jan-Feb;14(1):29-37.

Tables: Table 1: Measurements of semi-tendinosus specimens(MeanSD) Table 2: Size and bone density of femoral head specimens (N=18)(MeanSD) Table 3: Results of all mechanical tests (MeanSD)

Figures legend:

Figure 1: The TLS process, A. graft preparation, B. Graft fixation Figure 2: Fixation specimen set up Figure 3: All specimens UFL before and after cyclic loading ; Comparison with normal ACL failure load (Woo 1991) Figure 4: All specimens stiffness before and after cyclic loading ; Comparison with normal ACL stiffness (Woo 1991)

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Figure 5: Relationship between UFL and bone mineral density Figure 6: Elongation curve of three fixation specimens after 1500 cycles loading (50500N/2HZ)

Figure

Figure 1. The TLS process

4 2

5 3

A B Figure 3.Fixation specimen set up

A Graft preparation

C
B Graft fixation

Figure 2.Fixation specimen set up

Figure 3 All specimens UFL before and after cyclic loading ; Comparison with normal ACL failure load (Woo 1991)

Load (N)
2500 2000 1500 1000 500 0
ACL

ULTIMATE FAILURE LOAD

Normal ACL (Woo 1991) Before cyclic loading After 1500 cycles After 33600 cycles

GRAFT

FIXATION

COMPLEX G-F

Figure 4. All specimens stiffness before and after cyclic loading ; Comparison with normal ACL stiffness (Woo 1991)

N/mm
700 600 500 400 300 200 100 0
ACL

STIFFNESS

Normal ACL (Woo 1991) Before cyclic loading After 1500 cycles After 33600 cycles

GRAFT

FIXATION

COMPLEX G-F

Figure 5. Relationship between UFL and bone mineral density

2500
2000

UFL (Newton)

1500 1000 500 0 0 0,5 1 ROI Normalised 1,5 2

Figure 6: elongation curve of three fixation specimens after 1500 cycles loading (50-500N/2HZ)
NB: For better readability, the yellow and pink curves have been traced respectively with +1mm and +2mm offset.

Displacement(mm)

Time(sec)

Table

TABLE 1 Measurements of semi-tendinosus specimens(MeanSD)

Type of considered specimens Number of specimens Age Total length (cm) 4 strands loop length(cm) Suture length(cm) Diameter(mm)

All spec. 5 spec.tested before cyclic loading 5 spec.tested after cyclic loading

18 5

69 11 65 16.5

28.5 1.9 28.8 1.6

5.3 0.2 5.5 0.3

4.3 0.6 4.0 0.6

9.4 0.8 9.6 0.9

73 5

28.8 1.1

5.3 0.3

4.5 0.8

9.6 0.8

TABLE 2 Size and bone density of femoral head specimens (N=18)(MeanSD)

Femoral head thickness (cm) Whole head bone density(gr/cm2) after normalisation Range of interest(gr/cm2) after normalisation

49.3 4.3

0.86 0.14

1.14 0.19

TABLE 3 Results of all mechanical tests (MeanSD) Type of N Trials Ultimate failure load (N)
After 1500cycles (20500N) After long duration cyclic loading Before cyclic loading

Stiffness (N/mm)
After 1500cycles (20500N) After long duration cyclic loading

Elongation(mm)
After 1500cycles (20500N) After long duration cyclic loading

Before cyclic loading

Graft only

5 5 5 1

1302 140

_ 1916 349 _ 1535 370 _

_ _ _ _ 1330(a)

262 23 _ 384 56 _ _

_ 605 40 _ 452 113.2 _

_ _ _ _ 402(a)

_ 3.5 0.4 _ 0.6 0.2 _ 6 1.5* 1.2 0.2** (n=4) _

_ _ _ _ 0.25(a)

_
1742 397

Fixation 4 only

_ _

Compl. Graftfixation

1568 247

232 23.5

7.6 0.8*(b) 2.6 0.2**(b)

1553 362(b)

223 22(b)

a : after 6600 cycles loading (50-500N) b : after 33600 cycles loading (25-250N/50-500N)

*total rate of elongation without preconditioning **total rate of elongation with preconditioning